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Treatment of a Total Obstructive Anastomosis Stricture Using a Transanal Laparoscopic Approach and Intraoperative Colonoscopic Balloon Dilatation

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Treatment of a Total Obstructive Anastomosis Stricture Using a Transanal Laparoscopic Approach and Intraoperative Colonoscopic Balloon Dilatation Annals of Case Report Coloproctology Ann Coloproctol 2020;36(5):353-356 pISSN 2287-9714 eISSN 2287-9722 https://doi.org/10.3393/ac.2020.02.27 www.coloproctol.org Treatment of a Total Obstructive Anastomosis Stricture Using a Transanal Laparoscopic Approach and Intraoperative Colonoscopic Balloon Dilatation Jae Young Kwak1, Kwan Mo Yang1, Hyun Il Seo2 Departments of 1Surgery and 2Internal Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea An anastomosis stricture with a total obstruction is rare and treatment options are variable. We describe our experience with a combination of a single port transanal laparoscopic approach and intraoperative colonoscopic balloon dilatation. The patient was a 48-year-old man with rectal cancer. A laparoscopic single port lower anterior resection and diverting il- eostomy were performed followed by a colon study and ileostomy takedown. The colon study and sigmoidoscopy revealed total obstruction of the rectum at the anastomosis level. We employed a transanal approach using a single port to correct this. We located the anastomosis stricture site and generated a lumen using a dissector and electocautery method to insert the balloon device. Colonoscopic balloon dilatation was subsequently successful. The patient was discharged with no postoperative complications. A laparoscopic single port transanal approach with an intraoperative colonoscopic balloon dilatation is a viable alternative approach to treating an anastomosis stricture of the rectum. Keywords: Anastomosis; Stricture; Transanal; Balloon INTRODUCTION stenting. Anastomosis strictures also have several different types [5] which need to be considered when selecting the most appro- A rectal anastomosis stricture is a rare but not insignificant possi- priate treatment option. ble complication of rectal surgery. Its incidence varies from 2% to Our present case report describes our experience with a combi- 30% [1-3] and is higher in patients undergoing postoperative ra- nation treatment of a single port laparoscopic transanal approach diotherapy and stapled rather than hand-sewn coloanal anasto- and intraoperative colonoscopic balloon dilatation in a patient mosis [1]. The management of a rectal anastomosis stricture var- with an anastomosis site stricture with near-total obstruction. ies from major pelvic surgery to local revision. Garcea et al. [4] re- viewed these approaches and reported that the most common in- CASE REPORT tervention was dilation only, with other treatments including pel- vic revision surgery, fecal diversion, transanal microsurgery, stric- A 48-year-old man was referred to our hospital for the evaluation tureplasty, Hegar dilatation, electrocauterization, and mechanical of hematochezia for 10 days. A colonoscopy revealed a polypoid rectal adenocarcinoma at 10 cm above the anal verge. A com- Received: Nov 5, 2019 • Revised: Feb 11, 2020 • Accepted: Feb 27, 2020 puted tomography and magnetic resonance imaging revealed no Correspondence to: Hyun Il Seo, M.D. Department of Internal Medicine, Gangneung Asan Hospital, University of evidence of pericolic fat infiltration, lymph node metastasis, or Ulsan College of Medicine, 38 Bangdong-gil, Sacheon-myeon, Gangneung distant metastasis. The patient wanted surgical treatment than 25440, Korea endoscopic resection. He underwent a single port laparoscopic Tel: +82-33-610-3945, Fax: +82-33-644-5495 low anterior resection and diverting ileostomy. Inferior mesen- E-mail: [email protected] teric artery was ligated at the level of origin and rectal anastomo- ORCID: https://orcid.org/0000-0002-0339-5031 sis was performed using a double‐stapling technique with 28-mm © 2020 The Korean Society of Coloproctology EEA Circular Stapler (Medtronic Inc., Minneapolis, MN, USA) at This is an open-access article distributed under the terms of the Creative Commons Attribution Non- the level of 8 cm above anal verge. He was hemodynamically sta- Commercial License (https://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non- commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. ble after surgery with no detectable postoperative complications. www.coloproctol.org 353 Treatment of a Total Obstructive Anastomosis Stricture Using a Transanal Laparoscopic Approach and Annals of Intraoperative Colonoscopic Balloon Dilatation Coloproctology Jae Young Kwak, et al. The tumor pathology indicated a TisN0M0 lesion. The patient scope balloon dilatation was then done under endoscopic visual- made a full recovery and was discharged 7 days later. At 2 months ization of the stenosis. A controlled radial expansion balloon dila- postsurgery, a colon study was performed for an ileostomy take- tor (CRE PRO Wireguided, 12-mm/13.5-mm/15-mm diameter; down but revealed a total obstruction of the rectum at the anasto- Boston Scientific, Cork, Ireland) was inserted through the stric- mosis level. We could exclude other reasons for anastomosis ob- ture and distended for 1 minute for each diameter. No fluoro- struction such as tumor or other extraluminal problem with ab- scopic control was used during the balloon dilation and the pro- dominopelvic computed tomography scan. A subsequent sig- cedure was completed successfully with no complications. The moidoscopy confirmed that an anastomosis site stricture was the patient was discharged 7 days after this operation without postop- cause (Fig. 1). erative complications. A follow-up 3 months later found no other We decided to employ a transanal approach using a single port adverse events with normal sigmoidoscopic findings and ileos- (GelPOINT Path, Applied Medical, Rancho Santa Margarita, CA, tomy takedown was done successfully (Fig. 3). USA) to correct this obstruction. We located the anastomosis The Institutional Review Board of Gangneung Asan Hospital stricture site and generated a lumen using a dissector and electro- approved this study and waived the informed consent require- cautery method to insert a balloon device (Fig. 2). Through-the- ment (No. GNAH 2019-05-011). A B Fig. 1. Colon study (A) and sigmoidoscopy (B) of the patient revealing a total obstruction of the rectum at the anastomosis level. A B Fig. 2. Transanal electrocautery (A) was used to generate a lumen followed by colonoscopic balloon dilatation (B). 354 www.coloproctol.org Volume 36, Number 5, 2020 Annals of Ann Coloproctol 2020;36(5):353-356 Coloproctology adverse events including abscess, transient septicemia, and tech- nical failure [4]. The transanal strictureplasty technique using a circular stapler has a reported success rate of 64%. However, this particular method is not really feasible in cases of very tight ste- nosis, which a stapler cannot pass through. Moreover, there is a higher risk of fistula formation and ischemic change complica- tions with this approach [4, 10]. Stenting has been rarely reported as the chosen management option for an anastomosis stricture as migration, erosion, pressure necrosis, and bleeding are considered to be high-risk complications of this method [4]. Surgical man- agement with laparotomy requires extensive pelvic dissection and is therefore a potentially dangerous procedure. It may be needed however in cases of dilatation or endoscopic technique failure, transanal approach failure, or for severe long segment stenosis. Resection of the anastomosis site and reconstruction with a new stapled anastomosis can be a surgical option in patients with fa- vorable local conditions; if the conditions are unfavorable, recon- struction with a straight coloanal anastomosis or permanent co- Fig. 3. Sigmoidoscopy findings at 3 months later after the procedure. lostomy are possible surgical options [3]. An anastomosis stricture with a total obstruction is a rare but DISCUSSION serious complication for which a consensus management option is yet to be established. In our current case, it was difficult to pre- The term anastomosis stricture can be used to refer to a narrow- operatively assess the length and severity of the stenosis. We ing in the colon that prevents a normal passage of the stools, but therefore chose and successfully applied a combination treatment there is no clear definition. Because of this lack of a consensus in involving a transanal laparoscopy to create a lumen and prevent defining a ‘true’ anastomosis stricture, the incidence of this com- bleeding or perforation and balloon dilatation. We introduce plication has been reported at a wide range, from 2% to 30% [1-3]. carefully our experience with this method that it is a viable alter- Most reported instances of anastomosis stenosis have occurred native for the treatment of anastomosis stricture with total ob- within 6 months of surgery [6]. struction of the rectum. Ischemia of the suture line, leakage, inflammation, and hemor- rhage have been proposed as underlying pathophysiological CONFLICT OF INTEREST mechanisms of postoperative rectal anastomosis strictures, with risk factors reported to include stapled anastomosis, radiotherapy, No potential conflict of interest relevant to this article was re- diverticulitis, and the level and tension of the anastomosis [1-3, 6, ported. 7]. A stapled anastomosis is associated with higher levels of colla- gen deposition and inflammation, which may lead to stenosis for- REFERENCES mation [8]. Radiotherapy can also cause histologic alterations such as obliterative endarteritis, tissue ischemia and necrosis, and 1. Neutzling CB, Lustosa SA, Proenca IM, da Silva EM, Matos
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